Impact of the Hospital Frailty Risk Score on Outcomes following Primary Total Elbow Arthroplasty.

BACKGROUND: The Hospital Frailty Risk Score (HFRS) has demonstrated strong correlation with adverse outcomes in various joint replacement surgeries, yet its applicability in total elbow arthroplasty (TEA) remains unexplored. The purpose of this study is to assess the association between HFRS and postoperative complications following elective primary TEA. METHODS: The Nationwide Readmissions Database was queried to identify patients undergoing primary TEA from 2016 to 2020. The HFRS was used to compare medical, surgical, and clinical outcomes of frail vs. non-frail patients. Mean and relative costs, total hospital length of stay (LOS), and discharge disposition for frail and non-frail patients were also compared. RESULTS: We identified 2,049 primary TEA in frail patients and 3,693 in non-frail patients. Frail patients had increased complication rates including acute respiratory failure (13.6% vs. 1.1%; p < 0.001), urinary tract infections (12.3% vs. 0.0%; p < 0.001), transfusions (3.9% vs. 1.1%; p < 0.001), pneumonia (1.1% vs. 0.2%; p < 0.001), acute respiratory distress syndrome (3.2% vs 0.6%; p < 0.001), sepsis (0.7% vs. 0.1%; p < 0.001), and hardware failure (1.2% vs 0.1%; p < 0.001). Frail patients also experienced higher rates of readmission (37% vs. 25%; p < 0.001) and death (1.7% vs. 0.2%; p < 0.001), while being less likely to undergo revision (6.5% vs. 17%; p < 0.001). Frail patients incurred higher healthcare costs ($28,497 vs. $23,377; p < 0.001) and longer LOS (5.3 days vs. 2.6 days; p < 0.001), with reduced likelihood of routine hospital stays (36% vs. 71%; p < 0.001) and increased utilization of short-term hospitalization (p < 0.001), care facilities (p < 0.001), and home health care services (p < 0.001). CONCLUSION: HFRS is a validated indicator of frailty and is strongly associated with increased rates of complications in patients undergoing elective primary TEA. These findings should be considered by orthopedic surgeons when assessing surgical candidacy and discussing treatment options in this at-risk patient population.

Discharge with Home Health Care is Associated with Increased Complications, Readmission, and Mortality Following Total Shoulder Arthroplasty.

INTRODUCTION: Patients undergoing primary anatomic and reverse total shoulder arthroplasty (TSA) are often discharged with home health care (HHC) to provide access to at-home services and facilitate postoperative recovery and continued medical management. The purpose of this study is to evaluate the short-term postoperative outcomes of patients following primary TSA discharged with HHC, including medical and surgical complications, total cost of care, and total hospital length of stay (LOS). METHODS: The Nationwide Readmissions Database (NRD) was reviewed for patients who underwent elective primary TSA between 2016 to 2020 for a retrospective cohort analysis. Patients were stratified by discharge status following the inpatient admission, with 32,497 patients discharged with HHC and 116,402 patients discharged routinely with self-care. Patient demographics, preoperative medical comorbidities, postoperative medical and surgical complications within 180 days, cost of admission, and total hospital length of stay (LOS) were compared between the two discharge groups using Chi-squared analyses. Further multivariate analysis was conducted to control for independent prognosticators on the effect of HHC on postoperative outcomes. RESULTS: Discharge with HHC was correlated with significantly increased rates of all-cause medical complications (OR 1.6, p < 0.001), surgical site infection (SSI) (OR 2.8, p < 0.001), hospital readmission (OR 1.3, p < 0.001), and death (OR 2.1, p < 0.001) within 180 days of primary TSA. Multivariate analysis suggests these correlations are independent risk factors and not due to patient demographics or preoperative medical comorbidities. While discharge with HHC was found to be associated with increased hospital LOS (1.8 vs. 1.3 days, p < 0.001), there were no significant observed differences in cost of care. CONCLUSION: This study demonstrates that discharge with HHC compared to routine discharge while accounting for several preoperative comorbidities and demographic variables is associated with increased medical complications, SSI, readmission, and death within 180 days of TSA, but no increase in overall patient cost. These findings suggest HHC disposition status can serve as a prognosticator for postoperative complications and can help guide clinician decision making when determining appropriate surgical candidacy.

Non-Home Discharge is an Independent Risk Factor for Readmission Following Primary Total Shoulder Arthroplasty.

INTRODUCTION: Utilization of total shoulder arthroplasty (TSA) in the United States has increased substantially within the last two decades and this trend is expected to continue. As TSA volume has continued to increase, healthcare policy has shifted towards an emphasis on value-based care. Therefore, it is important to understand variables that may increase TSA costs, including readmission rates. Patients discharged to home healthcare (HHC) or post-acute care (PAC) facilities have demonstrated increased readmission rates following TSA. However, few studies have directly compared HHC to PAC facilities and routine home discharge while accounting for pertinent demographics. The purpose of this study was to compare 180-day readmission rates between routine home discharge, HHC, and PAC facility groups following primary TSA. METHODS: The Nationwide Readmissions Database was queried from 2010 to 2020 to identify all patients that underwent primary TSA. Readmission rates were compared between routine home discharge, HHC, and PAC facility groups. Binary logistic regression identified independent risk factors for readmission within 180 days. RESULTS: From 2010 to 2020 a total of 171,898 patients underwent TSA. 71% were routinely discharged home, 21% were discharged to HHC, and 8% were discharged to a PAC facility. After adjusting for income, insurance, obesity status, age, Charlson Comorbidity index, and gender, discharge to a PAC facility was independently predictive of readmission within 180 days following TSA (OR: 1.69, 95% CI 1.59-1.79, p<0.001). CONCLUSION: Patients discharged to a PAC facility after TSA had higher readmission rates compared to HHC and routine home discharge that persisted even after controlling for relevant demographics. Clinicians should be cognizant of the risks and benefits of different discharge methods and consider home discharges for suitable candidates. Understanding risk factors that increase healthcare expenditures has significant utility for institutions in the era of bundled care. However, it is important that alternative payment models do not disincentivize orthopedic surgeons from providing care to medically complex patients.

Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report.

CASE: A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal. CONCLUSION: Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

The Prevalence of Shoulder and Elbow Pathology in Major League Baseball Prospects From the Dominican Republic.

BACKGROUND: Rates of shoulder and elbow pathology are well documented among competitive baseball players in the United States; however, little is known about the prevalence of these pathologies in the Dominican Republic (DR). PURPOSE: To report the epidemiology of shoulder and elbow pathology among participants at a Major League Baseball scouting event in Santo Domingo, DR. STUDY DESIGN: Retrospective descriptive study. LEVEL OF EVIDENCE: 3. METHODS: All pitchers and position players who attended the 2021 scouting event were reviewed. Those with complete medical history, physical examination, imaging series, and radiology reports were included. All participants underwent shoulder and elbow radiography, while pitchers also underwent magnetic resonance imaging (MRI). All pathologic findings on imaging studies were recorded and compared among position players and pitchers. RESULTS: Seventy-five participants (average age, 17.9 years) were reviewed (42 position players, 33 pitchers); 72% and 32% had ≥1 abnormal finding on elbow and shoulder radiographs, respectively. Position players had significantly higher numbers of elbow radiographic findings compared with pitchers (81% vs 57.6%, P = 0.03) but similar numbers on shoulder radiograph (28.6% vs 33.3%, P = 0.66). Position players had high numbers of acromioclavicular separation (14.3%) and little leaguer's shoulder (14.3%) on shoulder radiograph, with olecranon osteophytes (23.8%) and medial epicondyle nonunions (11.9%) prevalent on elbow radiograph. Pitchers had high numbers of rotator cuff pathology (93.9%), labral tears (75.8%), and Bennett lesions (51.5%). On elbow imaging, pitchers had high numbers of ulnar collateral ligament (UCL) abnormalities (81.8%), olecranon osteophytes (69.7%), osteochondral lesions (18.2%), and medial epicondyle nonunions (12.1%). Two pitchers had complete UCL disruption (6.1%), while 8 had partial tears (24.2%). CONCLUSION: Dominican baseball prospects had high numbers of asymptomatic shoulder and elbow pathology on imaging studies. Knowledge of the prevalence of these pathologies can guide injury prevention programs in Dominican youth baseball.

Effects of Upper Extremity Elevation on Intra-Cast Pressure and Digital Perfusion in a Fiberglass Short-Arm Cast Model.

The goal of this study was to determine the relationship of digital artery pressure to arm position and forearm skin surface pressure using a short-arm cast experimental setup, to ascertain the safest position for the injured casted upper extremity. A total of 27 volunteers were placed in bilateral short-arm fiber-glass casts with an empty 50-mL bladder bag under the cast and attached to a pressure transducer. Digital systolic pressure (Pdig), and skin surface pressure under the cast (Pskin) were assessed in 4 positions. Measurements were taken with and without 50 mL air in the bladder bag. A total of 54 forearms were evaluated. Both arm position and Pskin had a significant effect on Pdig (P<.001 for both), with increasing elevation leading to a decrease in Pdig (r=-0.50). The effect size of position on Pdig was large, whereas that of Pskin was small (partial eta-squared=0.371 and 0.028, respectively). Linear regression analysis of Pskin and Pdig with air in the neutral position yielded a moderate negative relationship with body mass index (r=-0.64, P<.001 for Pskin; r=0.49, P<.001 for Pdig) and wrist circumference (r=-0.66, P<.001 for Pskin; r=0.52, P<.001 for Pdig), without significant association with forearm length. For volunteers with short-arm fiberglass casts, increasing arm elevation had a large effect size on digital arterial pressure, whereas 50 mL simulated swelling had only a small effect size. Decreasing body mass index and forearm circumference correlated with increased skin surface pressure and decreased digital arterial pressure. These findings show that aggressive elevation of the injured limb may not be as desirable as previously believed. [Orthopedics. 2021;44(4):e487-e492.].

Risk Factors for Surgical Site Infections After Orthopaedic Surgery in the Ambulatory Surgical Center Setting.

INTRODUCTION: This study was designed to determine the incidence of surgical site infections (SSIs) after orthopaedic surgery in an ambulatory surgery center (ASC) and to identify patient and surgical risk factors associated with SSI. METHODS: Patients who underwent orthopaedic surgery at an ASC over a 6.5-year period were reviewed for evidence of SSI. Data on patient and surgical factors were collected, and stepwise multivariate logistic regression determined the risk factors for SSI. RESULTS: The incidence of SSIs was 0.32%. Five independent factors were associated with SSI: anatomic area (odds ratio [OR] = 18.60, 11.24, 6.75, and 4.01 for the hip, foot/ankle, knee/leg, and hand/elbow versus shoulder, respectively), anesthesia type (OR = 4.49 combined general and regional anesthesia versus general anesthesia), age ≥70 (OR = 2.85), diabetes mellitus (OR = 2.27), and tourniquet time (OR = 1.01 per minute tourniquet time). DISCUSSION: The risk of infection after orthopaedic surgery in ASCs is low, but patient and surgical factors are independently associated with SSIs.

Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center.

BACKGROUND: Overlapping surgery occurs when a single surgeon is the primary surgeon for >1 patient in separate operating rooms simultaneously. The surgeon is present for the critical portions of each patient's operation although not present for the entirety of the case. While overlapping surgery has been widely utilized across surgical subspecialties, few large studies have compared the safety of overlapping and nonoverlapping surgery. METHODS: In this retrospective cohort study, we reviewed the charts of patients who had undergone orthopaedic surgery at our ambulatory surgery center during the period of April 2009 and October 2015. A database of operations, including patient and surgical characteristics, was compiled. Complications had been identified and logged into the database by surgeons monthly over the study period. These monthly reports and case logs were reviewed retrospectively to identify complications. Propensity-score weighting and logistic regression models were used to determine the association between outcomes and overlapping surgery. RESULTS: A total of 22,220 operations were included. Of these, 5,198 (23%) were overlapping, and 17,022 (77%) were nonoverlapping. The median duration of surgery overlap was 8 minutes (quartile 1 to quartile 3, 3 to 16 minutes); no operations were concurrent. After weighting, the only continuous variables that differed significantly between the groups were operative time (median, 57 compared with 56 minutes for the overlapping and the nonoverlapping group, respectively; p = 0.022), anesthesia time (median, 97 compared with 93 minutes; p < 0.001), and total tourniquet time (median, 26 compared with 22 minutes; p = 0.0093). Multivariable logistic regression models did not demonstrate an association between overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, or morbidity. CONCLUSIONS: These data suggest that there is no association between briefly overlapping surgery and surgical site infection, noninfection surgical complications, hospitalization, and morbidity. When practiced in the manner described herein, overlapping orthopaedic surgery can be a safe practice in the ambulatory setting. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.